Guidelines to prescribing anti-psychotics to patients taking methadone for opioid use disorder. My take

Some Suggested Guidelines to Prescribing Anti-psychotics to Patients taking Methadone for opioid use disorder. 2024

By Donald H. Marks MD PhD   

With reference to disruptive patients with underlying psychosis or other mental health disorders in the presence of opioid use disorder, I want to bring up that prescribing and continuing methadone MTD for patients on antipsychotics can present several challenges, separate from psychological and counseling issues. As prescribers of methadone and refillers of antipsychotic medicines, we must consider several of these medical issues. Methadone used for opioid addiction treatment has drug-drug interactions between antipsychotics and methadone which can lead to adverse effects, and altered medication metabolism and effectiveness. Additionally, individuals on methadone may have complex medical and psychiatric histories, which can complicate treatment decisions for all these medicines. Close monitoring and coordination between healthcare providers and prescribing psychiatrists are crucial to ensure patient safety and optimal outcomes. 

Taking certain medications with CNS effects during treatment with methadone may increase the risk of serious or life-threatening side effects such as breathing problems, sedation, or coma. 

CNS drugs that can interact with MTD include : antipsychotics such as aripiprazole (Abilify), asenapine (Saphris), cariprazine (Vraylar), chlorpromazine, clozapine (Versacloz), fluphenazine, haloperidol (Haldol), iloperidone (Fanapt), loxapine, lurasidone (Latuda), molindone, olanzapine (Zyprexa), paliperidone (Invega), perphenazine, pimavanserin (Nuplazid), quetiapine (Seroquel), risperidone (Risperdal), thioridazine, thiothixene, trifluoperazine, and ziprasidone (Geodon); benzodiazepines such as alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clorazepate (Gen-Xene, Tranxene), diazepam (Diastat, Valium), estazolam, flurazepam, lorazepam (Ativan), oxazepam, temazepam (Restoril), and triazolam (Halcion); opiate (narcotic) medications for pain and cough; medications for nausea or mental illness; muscle relaxants; sedatives; sleeping pills; or tranquilizers. 

Patients should be monitored carefully, in conjunction / coordination with the prescribers of these CNS meds - their psychiatrists. Patients should be warned of adverse effects, such as  unusual dizziness, lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Caregivers or family members should be made aware, with the patient’s permission, of which symptoms may be serious so they can call the doctor or emergency medical care if the patient is unable to seek treatment on their own.

For the safety of patients and staff , we need to keep all these issues in mind. In particular, medical staff are not just the prescriber of medication but also doctors at MCAC and SCAC can be the drug (MTD) dispensors, so dispensing large quantities of medication can be problematic in terms of drugs interactions, safety, effectiveness, and danger to the patient and the community. 

Continued involvement with patients should be part of a multidisciplinary team , where everyone can have input and appropriate decisions can be made. 

References

1. Cocaine Use in the setting of Methadone treatment for Opioid Use Disorder

2. Methadone use during pregnancy

3. Marks DH. Evaluation of Cognitive Impairment. Internet J Health. 8(1), 2008.

4. Marks DH. Evaluation of Medical Causation, in Drug Injury: Liability, Analysis and Prevention, 3rd and 4th Editions,  O’Donnell JT editor. L&J Publications, 2012 and 2016.

5. Marks DH and Middlekoop T. Accutane: Focus on Psychiatric Toxicity and Suicide, in Drug Injury: Liability, Analysis and Prevention, Second Edition, Chapter 20. O’Donnell JT editor. L&J Publications, 2005.